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The Quarterly


Measuring the Measurers Print E-mail
The Quarterly 2011


The process of accreditation of hospitals is relatively untested. While some academic evaluation of the process and its outcomes has been applied over the last few years in Australia, the findings remain largely unpublished or inconclusive. Nor is it easy to rigorously asses whether accreditation achieves its aims, or if so, how well.

The rationale behind accreditation is laudable and broadly accepted. Are healthcare organisations achieving optimal health outcomes for their users while causing minimal harm and making best use of resources? Are they accountable? At least, do they meet minimal standards in their endeavours? By far the biggest accreditation body in Australia is the Australian Council on Healthcare Standards (ACHS), and it accredits the vast majority of healthcare organisations. Its current standards, EQuIP5, define minimum standards (and grade achievement across the spectrum of success). It is hoped that the National Standards currently being developed and tested, will do the same.

Yet questions remain as to the reliability, legitimacy and effectiveness of accreditation. Are hospitals that attain full accreditation 'safe' or 'good'? Are those that don't 'unsafe' or 'bad'? Are surveys thorough enough? Are they looking at the right things? Are surveys frequent enough, or too frequent? Is there inter-relater reliability between survey teams? In other words, we need to know that accreditation is worth the cost and that it works, and that we can rely on it. If the answers to these questions were to be 'no', we would need a viable alternative.

Organisations (usually hospitals, but also clusters, regional and area services) are surveyed for accreditation across all their operations. This demands a lot of the surveyors. These people are recruited from healthcare, and include administrators, corporate managers, doctors and nurses (the last group in large number). They collectively need a broad and deep knowledge of the clinical, corporate, safety and technical facets of healthcare. Their remuneration is meagre, their time demands high, and their professional and personal responsibilities great. 'Scoping' of surveys varies, but sometimes there are too few surveyors, too narrow a skill mix, or too little time. Moreover, it is very hard to reconcile professional biases, experiential variances and reporting styles. This makes the selection, training and performance management of surveyors all the more important. While there is research occurring into these things, as yet it is still not clear to all organisations and the healthcare sector at large, how these matters are managed.

It is difficult to compare the value of an ACHS accreditation plaque in the foyer of the Royal Prince Rupert Hospital or St Elsewhere's in the city with that of the plaque at Hicksville District (which may be one of a dozen little hospitals surveyed together in an Area survey). Certainly the tests of continuous improvement, evaluation and subsequent change, and the avoidance of unacceptable risk to safety and consumer involvement, can be applied to both. But the broader question remains of whether the accreditation process leads to measurable improvement of healthcare generally.

The process is still seen by many organisations as an 'event'. Although it should reflect a hospital's continuous improvement, it is impractical to review organisations more often than biennially. The ACHS has indeed commenced unscheduled and unheralded 'spot checks' in an attempt to make its own activities more continuous, and encourage organisations not to drop the ball. Nevertheless, the common pattern is for the quality coordinator to be flung into a vortex of frenetic activity just prior to survey, exhorting all and sundry (over whom she has little or no authority) to do things that should have been happening as a matter of course. Yet nearly all hospitals receive accreditation (albeit with recommendations, some of high priority), and breathe a sigh of relief after what they too often see as an unwelcome interruption to work, or embarrassment to the executive. The invaluable benefits of an external peer review often go unrecognized, or at least undervalued.

Like everything else, accreditation could be better designed, understood and performed. But equally importantly, it could itself be better evaluated. Perhaps that will happen in line with the Australian Commission on Quality and Safety in Healthcare's new national standards. There is some old literature (especially from the US Joint Commission) that has evaluated their accreditation. There are pre-eminent healthcare theorists (notably at UNSW) looking at the evidence base for accreditation here. It is now time that we had the evidence to justify and support accreditation; but without it, we will need to do something different.

Dr Chris Swan
RACMA Candidate

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